Hi,Im trying to rebuild atrophied quads - specifically VMO. I am dislocating very frequently as a result of this atrophy.MY OS tells me that my VMO is not firing. He says its from years of not using it properly, its atrophied, every dislocation shuts it down etc....Because my VMO is not firing I feel like my knee is trying to dislocate with every step I take. It DOES dislocate frequently when Im just walking slowly.

Ive finally gotten it firing 'manually' - as in I can contract it if I think about it.Problem is its still not firing automatically.

As an example, if I bend a little at the knees with my two legs, if you wiggle the kneecap on my good side its tight. If you wiggle the kneecap on the bad side its totally loose. If I try to contract the good side I find its already contracted. If I try to contract the bad side the whole knee tightens up and the kneecap is not floating around anymore. If only this contraction would happen by itself all would be ok!!

Ive been using an e-stim for almost 4 months now, twice a day. Ive also been on a new physio program for 4 months, specifically aimed at building VMO. VMO is responding, it has gone from being invisible to being there, its still much smaller than the good side, but you can see and feel that some muscle bulk has built up. There is a long way to go.

Im getting more and more concerned about the muscles not firing automatically. How can I make this happen!!! I feel like Im doing everything I can but nothing is working. Im constantly unstable, Im constantly in pain. The pain Im not too pushed about - the instability has caused me to stop all activities and now Im starting to feel like I live life in my living room because any walking is so risky.

My OS (first and second opinion) say all I gotta do is build the muscles and Ill be fine. My physio thinks I need surgery and just wont accept the OS's opinion. She is now talking about sending me to the UK to see a surgeon.

Thing is - I believe my OS cos its so obvious that VMO is tiny and not firing automatically but I just dont understand how Im gonna get it firing automatically. I just feel like Im killing myself with the exercises and no progress is being made functionally.

Has anyone any words of wisdom or advice? My OS has actually discharged me saying I didnt need anything but physio. But nothing seems to be changing and I feel like Im not living my life because I cant do anything that requires being on my feet without my knee feeling like its trying to dislocate - and frequently dislocating.

I know how hard you are trying and you are doing your best. I am right hear eager to read replies as whilst my knee isn;t dislocating after a LR I'm having my own fair share of probs with quad inhibition.

My physical therapist doesn't believe in the e-stim units to get your muscles firing. He says all they do is move your muscles but your brain has no idea why they are moving. He has a very unique way of getting muscles to work which requires a lot of concentration. After I had my PKR he would put his fingers on the muscle he wanted to fire and get me to concentrate on filling that space. It was hard at first but with a little practice I was able to do it and my muscles built up very quickly after that. He had muscles firing within a couple of sessions.

hi jathib,my PT has me doing leg raises and leg extensions while using the e-stim so that my brain knows why the muscles are moving. But it doesnt seem to be making any difference.Ive had dozens of sessions where I can 'manually' fire the muscles by concentrating like you said, but it doesnt seem to be translating into them automatically firing. And as long as they dont automatically fire I dislocate, as long as I dislocate I introduce more inhibition etc...etc...etc...I phoned my OS's secretary and told her the problems I am having, she said she will talk to him and phone me back this week.Tanya

TanyaAny chance at all that it isn't the knee muscles not firing but some neuron in your brain not firing correctly. You may be looking for horses when you need to be looking for zebras. Just a thought ( I don't have them often) CAROL

I think its just they wont fire automatically cos you can see when I 'manually' fire them that they DO contract (and if you have a feel of my kneecap when I contract them its real stable), the problem is they are not firing on their own - I can do a party trick demo where I bend slightly at the knee, show the wobbly kneecap, then manually contract and display no wobbles. Trouble is its not practical for me to keep on manually firing with every step I take, the minute I look at something or lose concentration for a second Kaboom - I dislocate cos I forgot to contract.

Im starting to wonder is pain causing problems here - I never complain about pain cos I guess Im so used to it I dont notice it. Its just the instability that gets to me. But maybe the muscles dont want to fire cos it hurts to contract? Cos it does hurt.

i really dont know what to think anymore. Every day is a huge struggle just trying to get about, but as much as I spend time working the leg (1 hour and 40 minutes a day between regular physio and e-stim) - its not working on its own.

Thats why my progress is slow in physio - everytime they test me on the isokinetic machine my improvement is not great cos the muscles are only moving when i move them by thinking about it.

Is it possible that the VMO is not firing and the knee keeps dislocating because the patella is too loose? You say that you can move your patella freely, which shouldn't happen. I know that when I had a lateral release, the doctor was extremely careful not to release it too much because she said that would cause more problems than it would solve. That's why a lot of times you hear that people are having a lateral release and a medial reefing....the reefing being the tightening. She explained that it was like guide wires on a tree....you loosen one side and tighten the other so the tree stays straight....but in this case it is the patella. If one of the ligaments is too loose, your patella dislocates. I'm not sure if this kind of "loose ligament" would show in an MRI. And remember, a MRI is not infallable. There are many, many instances of them showing things that aren't there and missing things that are. Maybe all this work on your quad isn't working because it's not the root cause of the problem? After all this time if your OS doesn't have an answer, perhaps it is time for a second opinion.

Janet - maybe you are right. This guy IS my second opinion - my first opinion sent me to physio that basically did nothing for 1.5 years, the second opinion says none of the exercises tried to get at VMO and that I was just wasting my time there. (This is also the opinion of my new PT) This OS is also the guy who done my original surgery, he says there is nothing mechanical wrong, he has done all the ligament tests etc... (you know where he pulls at your leg to see what gives), and he is saying that the fact I can 'manually' tighten it and when I do you cant budge the kneecap proves (to him) that its all a matter of getting muscles firing. Sounds convincing doesnt it? Hmmm...its not when youre living it!!!They already did an LR and medial reefing on me - he thinks I ripped the medial reefing around 12 years ago because I had a big dislocation that left me swollen and on crutches for months. In his opinion although it was probably ripped, I still had a functioning leg for the next 10 years so its all muscular.......

Jathib - youre lucky you didnt need the extra help - Im gonna stick with it cos after 2 years of physio to no avail I need all the help I can get.

I'm not sure I would call a knee that dislocates like yours a "functional leg"! It took me four different surgeons before I found one that knew what my problem was.

I had an advanced (so I was told) home e-stim unit that I used for several months, 30-40 minutes twice a day. It did nothing except hurt like crazy. But I assume they do work for some people or else the doctors wouldn't prescribe them. I agree that it can't hurt to give it a try.

Yeah Janet - I agree, how functional was it ever!! Thing is it used to only dislocate if I landed hard on it, or twisted suddenly, or fell badly on it - all sort of unusual situations. A number of OS's agreed that anatomically I was just unlucky and if I put it under stress it would dislocate. But Id a completely normal life, wore high heels, went dancing, hill walking, wind surfing, cycling to work etc... If I was doing something like windsurfing I would wear a support. The only think I could do was run hard on it - I could jog a little but it never held up to running.

That was considered functional (this is all post surgery) - all the OS's kept saying for years was that the stabilization surgery was all that they could do without causing more problems and I needed to keep the muscles strong to minimize dislocations.

But over time I got a desk job, I got a car - stopped cycling to work, and bit by bit my muscles just atrophied away without me even noticing until a huge dislocation 2 years ago that according to my current OS, shut down my muscles and they havent woken up again since. He thinks I skated on the edge for a long time with the knee and only kept it going cos I was cycling etc.. But its his opinion now that because I was never ever able to run on it since my surgery that it was never brought back to FULL function.

Well the e-stim has definitely started the muscle waking up - I had NO VMO, now I have a small one - and a lot of the exercises Im doing are the same as the ones before e-stim. So I dont doubt its helping wake it up - but it just wont stay awake.

Sorry for moaning - Ive been very stressed the past few days with my knee. Its just so unstable. Im so tempted to use crutches but every time I do my PT and OS go mad and tell me to get off them. But I just dont know how Im expected to get about.